Introduction

The public and its elected officials are changing some of their tune on the loosening of drug laws, and there is evidence that the attitude shift is justified. As states’ populations perceive less of a risk in using marijuana, they tend to perceive less of a risk in using harder drugs. In light of the deadly substances being smuggled across the southern border, this dwindling scare factor coincides with deadly consequences. 

The legalization and industrialization of marijuana began in 2012 and continues. This trend followed a decades-long campaign that included both marijuana specifically and other drugs more broadly. Attitudes towards drug offenses shifted in the late 2000s from the punitive approaches of the 1990s. Between 2009 and 2013, 40 states eased their drug laws, according to a Pew Research Center analysis. In the late 2010s and early 2020s, some states continued loosening their laws to the point of de facto or explicit decriminalization. 

The broader attitudes of drug reform, however, have run concurrently with rising overdose rates and the rise of a deadly synthetic drug, fentanyl. As public attitudes grew less fearful of drugs in general, drug overdoses rose. In the wake of drug reform, states are shifting their attitudes back towards stiffer penalties. 

Government data draws a clear line between the broader acceptance of drug use and the negative consequences, including substance abuse disorder and overdose deaths. It is critical leaders understand the broader implications of loosening drug laws, particularly as the widespread legalization of marijuana has become embedded. 

Key Findings

• When comparing states, overdose rates are highest in states where marijuana is fully legal, second highest in states where marijuana is legal for only medical reasons, and the lowest for states where marijuana is fully illegal. 
Figure 1 - Average Overdose Deaths Rate Among States by Marijuana Legal Status
•  For states in which marijuana is fully legalized at a recreational level, the average overdose rate was 38 deaths per 100,000 in 2022.
• For states where marijuana was of mixed legality (medically legal but not recreationally), the average overdose rate was 33 per 100,000 in 2022.
• In states where marijuana is illegal both medically and recreationally, the average overdose death rate was 28 per 100,000 in 2022.
• Public attitudes and drug laws have been growing more lenient in the last two decades as marijuana and psychedelics have been legalized, according to data from the U.S. Substance Abuse and Mental Health Administration.
• The number of fentanyl pills seized in the U.S. increased by a factor of 2,300 between 2017 and 2023.
• The cost of fentanyl overdose in two states with recently passed lenient drug laws, Colorado and Oregon, was a combined $47 billion in 2023.
• The national rate of overdoses doubled from 1999 to 2012, then doubled again between 2012 and 2023. Colorado’s number of overdoses followed the same pattern.
• Data shows a positive correlation between rising public acceptance of drug use and overdoses.
• Early adopters of marijuana legalization are cases in point. Colorado, Washington, Oregon, and Alaska each rank highly against other states for marijuana use, illicit drug use, substance use disorder rates, and overdose rates, while ranking lowly for perceptions of great risk of marijuana, cocaine, or heroin usage.

Leniency’s Link to Higher Use Rates and Overdose 

More relaxed attitudes towards drug use are positively correlated with overdose death rates, according to a cross-comparison of U.S. Centers for Disease Control and Prevention and U.S. Substance Abuse and Mental Health administration data. The overdose rate in states in which marijuana is illegal is only 71% the overdose rate of states in which marijuana has been legalized. 

There is a preponderance of correlations between higher social tolerance of drugs and negative outcomes including substance use disorder and overdose. Higher tolerance levels also correlate with higher substance use disorder rates and, ultimately, higher rates of overdose deaths. 

This trend is ultimately borne out by the confluence of overdose rates and marijuana legalization status. The states which have fully legalized marijuana have higher overdose rates than states where marijuana has a mixed legal status, which in turn have higher overdose rates than states in which marijuana is fully illegal. 

In states where marijuana is illegal both medically and recreationally, the average overdose death rate was 28.22 in 2022. For states where marijuana was of mixed legality (medically legal but not recreationally), the average overdose rate was 33.4 in 2022. For states in which marijuana is fully legalized at a recreational level, the average overdose rate was 38.53 in 2022. 

Data from the Substance Abuse and Mental Health Administration makes this trend more clear. The data does not point to marijuana being a gateway drug; rather, it points to the reality that social tolerance of drugs is connected to drug use.

The states with higher social tolerance levels of marijuana also have higher social tolerance levels for harder drugs such as heroin and cocaine. This is measured by SAMHSA survey data in which respondents report their perceptions of great risk of a certain drug. A lower perception of great risk would indicate a higher level of social tolerance. 

Figure 2 – Perceptions of Great Risk of Monthly Marijuana and Cocaine Use by State (2022)

Figure 2 shows the correlation between perception of great risk in each state for monthly marijuana use and monthly cocaine use according to SAMHSA survey data from 2022. For example, in 2022, 14% of survey respondents perceived a great risk from smoking marijuana once a month and 54% perceived a great risk from using cocaine once a month. Survey data shows a strong positive correlation between marijuana and cocaine social tolerance, with correlation coefficient of 0.76. States in which people do not perceive a great risk from monthly marijuana usage correspond to states in which people do not perceive a great risk from cocaine use. 

The same is true of marijuana and heroin. As shown in Figure 3, states with lower perceptions of risk from marijuana also have lower perceptions of risk from trying heroin once or twice. This is also a positive correlation, with a correlation coefficient of 0.6. 

Figure 3 - Perceptions of Great Risk of Monthly Marijuana and Trying Heroin Once or Twice by State (2022)

Simply put, tolerance of drugs is not specific to one drug. Tolerance is not simply a public policy attitude, either. The more tolerant the attitudes in a state, the more likely the state’s residents are to be using drugs generally. 

Figure 4 - Perceptions of Great Risk of Monthly Marijuana Use and Illicit Substance Use in the Last Month (2022)

Figure 4 shows the connection between perceptions of great risk of marijuana and illicit substance use in the past month. There is a strong negative correlation between the two, with a correlation coefficient of -0.68. In states in which respondents have a low perception of risk of marijuana, there is a larger share of respondents who reported using an illicit substance other than marijuana in the last month. 

The same is true with perceptions of great risk of cocaine use. There is an equally strong correlation between perception of risk regarding cocaine usage and illicit substance use, with a correlation coefficient of -0.66. The less the population sees a risk, the more likely it is to use illicit substances.

Figure 5 - Perceptions of Great Risk of Monthly Cocaine Use and Illicit Substance Use in the Last Month by State (2022)

Figure 6 - Illicit Substance Use in The Past Month and Substance Abuse Disorder in The Past Year (2022)

The more a state’s residents use illicit substances, the more likely they are to develop higher rates of substance use disorder. Figure 6 shows a strong positive correlation between states’ illicit substance use rates and the rates of substance use disorder reported in the last year, with a correlation coefficient of 0.77. States with higher rates of illicit substance use have higher rates of substance use disorder and vice versa.

Similarly, states with higher rates of illicit substance abuse are more likely to have higher rates of overdose deaths, as shown in Figure 7. This relationship has a weaker positive relationship, with a correlation coefficient of 0.35. 

Figure 7 - Illicit Substance Use in The Past Month and Overdose Deaths Per 100,000 By State (2022)

Taken as a whole, there is a positive link between normalization of drug use of any kind, drug use itself, substance use disorder, and overdose death rates. 

Early adopters of marijuana legalization are cases in point. Colorado, Washington, Oregon, and Alaska each rank highly against other states for marijuana use, illicit drug use, substance use disorder rates, and overdose rates, while ranking lowly for perceptions of great risk of marijuana, cocaine, or heroin usage (see appendix).

Drug Leniency Over Time

These trends have borne out nationally over time. The 2010s were a fruitful time for drug reformers. Marijuana has become broadly legalized and attitudes towards drug use have become more relaxed.

The National Organization for the Reform of Marijuana Laws had a series of successes in the 20th century scoring state-level legalizations of medical marijuana. Eventually, strategies shifted to the legalization of recreational marijuana, backed not only by NORML but by similar organizations and business interests. Colorado and Washington both legalized marijuana in 2012, followed in 2014 by Oregon and Alaska. As of 2024, the majority of Americans live in a state in which recreational marijuana is legal, spread through 24 states and the District of Columbia. Marijuana now represents a multi-billion-dollar business, while state and local governments harvest tax revenue.

Nationally, attitudes towards drugs became less fearful as the 2010s passed. In 2014, 27% of the nation perceived a great risk in smoking marijuana once a month. That declined to 21% by 2022. Similarly, 72% of Americans perceived a great risk from monthly cocaine use. That dropped to 66% by 2022. The perception of great risk in trying heroin once or twice dropped from 85% to 82%. 

Figure 8 - Change in U.S. Perception of Great Risk Associated with Various Drugs

Psychedelic drug legalization campaigns followed the structure marijuana campaigns established, some successfully. Two states, Colorado and Oregon, have decriminalized possession of psilocybin mushrooms. Colorado decriminalized by means of a ballot measure in 2022 and Oregon by ballot measure in 2020. 

Several other states have active legislation to decriminalize psychedelic drugs, including Alaska, California, Illinois, Massachusetts, Michigan, North Carolina, Pennsylvania, and Wisconsin. Other states are studying psychedelic medical applications, including Arizona, Connecticut, Illinois, Maryland, Minnesota, New Mexico, and Washington.

Denver had already virtually decriminalized mushrooms by ballot measure in 2019. A dozen cities around the country have done the same, including: Port Townsend and Seattle, Washington; Arcata, Berkeley, San Francisco, Santa Cruz, and Eureka, California; Minneapolis, Minnesota; Ann Arbor, Ypsilanti, Ferndale, Hazel Park, and Detroit, Michigan; Portland, Maine; Easthampton, Amherst, Somerville, Northampton, Cambridge, and Salem, Massachusetts; and the District of Columbia.

Arguably, marijuana and psychedelics have a milder reputation than the harder drugs that cause overdose deaths in great numbers. As marijuana and psychedelics legalization campaigns have gained momentum, states have also begun decriminalizing other drugs. 

Oregon voters approved a ballot measure, Measure 110, in 2020 that made possession of all drugs, including heroin and methamphetamine, a civil offense rather than a criminal one. In Colorado, legislators passed a similar bill, House Bill 19-1263, that reduced the penalty for possession of less than four grams of any substance to a misdemeanor rather than a felony. In Washington, a state Supreme Court decision effectively decriminalized drug possession. Temporary rules made possession a misdemeanor from 2021 to 2023. 

Fentanyl

The newfound drug laxity and social tolerance coincided with the rise of fentanyl as the nation’s biggest drug threat. The synthetic opioid became a favorite import of Mexican drug cartels in the 2010s, as it is more potent than heroin, easier to smuggle across the border, and cheaper and more convenient to produce. 

Figure 9 - Number of Pills Containing Fentanyl Seized by Law Enforcement in the United States, 2017-2023

Seizures in the Mountain West alone show progressively larger amounts of fentanyl seized in the western U.S. each year, as examined in a Common Sense Institute report in 2024. The DEA’s Rocky Mountain Field Division seized a record 425.6 kilograms of fentanyl in 2023.  The number of reported narcotic seizures by the Colorado Bureau of Investigation has increased 104.4% from 3,367 in 2008 to 7,434 in 2023. The quantity (dosage units) of narcotics seized has increased 5,144% from 4,044 units in 2008 to 212,077 units in 2023.

Figure 10 - Narcotics Seizures (Number of Reports and Quantity) in Colorado

Fentanyl-specific death rates rose with seizures. In 2023, there were over 1,200 drug overdose deaths from fentanyl, 59% of which resulted from illegally manufactured fentanyl. This is approximately three deaths per day on average. This is more than the number of people killed in homicides in Colorado in 2021, 2022, and 2023 combined (1,146).

Economically, fentanyl has been devastating. In two states alone, this single drug accounts for a combined loss of $47 billion in 2023. The total cost of fentanyl-related overdose deaths in Colorado is estimated to be $16 billion in 2023. This is over ten times the cost of fentanyl overdose from 2017, $1.3 billion. In Oregon, the cost of the fentanyl crisis is more than $31 billion annually, up from $5.88 billion in 2017. 

National Drug Induced Deaths

Fentanyl’s presence accelerated the trend of rising overdose rates that began in 1999. The United States is in the throes of record rates of drug induced deaths. Nationally, between 1999 and 2022, the U.S. rate of overdose deaths increased by nearly 400%.

Figure 11 below shows the rapid increase in the rate of drug induced deaths nationally. Drug overdose death rates have been rising annually since 1999, but were relatively level between 2006 and 2012. Only in 2007 did national drug overdose rates decrease from the prior year. 

Since 2012, the rate of increase in annual drug overdose deaths rose sharply. Rates rose by 116% since 2014. 

Figure 11 - U.S. Drug Induced Deaths per 100,000 (1999-2022)

The raw number of drug overdoses increased by 124% on average amongst the 50 states and D.C. due to the massive increase in nearly every state, Colorado performed better than average despite a 105% increase in the number of drug overdose deaths. Alaska, Oregon, and Washington, however, performed below average in both categories. 

In Colorado, overdose rates in 2023 were higher than in any year but 2021. Since 2019, the overdose rate has increased 74% - over half of which were fentanyl-related. 

Figure 12 - Colorado Total Overdose Deaths 2000-2023

Walkbacks and Bottom Line

States are beginning to reconsider their policies on drug decriminalization

Oregon voters passed Measure 110 in November 2020, making it the first state to decriminalize the possession of small amounts of all drugs. After the law took effect, however, there was an increase in visible drug use and overdose deaths and difficulties steering users into treatment. The public attitude shifted, and the Oregon Legislature reinstated criminal penalties for the possession of small amounts of hard drugs in 2024. 

In 2024, Washington lawmakers this year raised the state’s penalty for drug possession to a gross misdemeanor and criminalized public drug use. California Gov. Gavin Newsom vetoed a measure in California that would have opened safe injection sites, and a ballot initiative was introduced in that state to increase drug possession penalties.

It is critical that states consider drug decriminalization history in their ongoing discussions of law, order, and public health. As states have dialed back their drug laws in the last two decades, the nation has been introduced to a deadly drug and seen skyrocketing overdoses. Whatever the justification for more lenient drug laws, data suggests that drug use becomes more widespread in places that perceive less of a risk in their use. This has profound implications, including the potential for increasing overdose deaths.

Appendix and Methodology

Calculating the costs of fentanyl overdose deaths:

The Center for Disease Control and Prevention (CDC) methodology from “State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose – United States, 2017” was used to estimate the cost of an opioid overdose in Colorado and Oregon. The CDC estimated the cost of fatal opioid overdoses for thirty-eight states and DC in 2017. The CDC used a case count of 578 fatal opioid overdoses, a per death cost of $11.5 million. Using this same approach CSI estimated the cost per death and total costs in 2018 through 2023 by inflating the per death costs in each category by the Personal Consumption Expenditure Price Index (excluding energy and food). 

SAMHSA Survey Rankings Among Four First States To Legalize Marijuana

Substance Use Disorder in the Past Year (2022)

Illicit Drug Other Than Marijuana in the Last Month (2022)

Marijuana Use in the Past Year (2022)

Methamphetamine Use in the Past Year (2022)

Cocaine Use in the Past Year (2022)

Heroin Use in the Past Year (2022)

Prescription Pain Reliever Misuse in the Past Year (2022)

Perceptions of Great Risk from Smoking Marijuana Once a Month (2022)

Perceptions of Great Risk from Using Cocaine Once a Month (2022)

Perceptions of Great Risk from Trying Heroin Once or Twice (2022)